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Hello, good evening. Uh My name is Sophia. Um I think we only have is it Paul who's watching at the minute, but Dee will be joining us later and we'll see if there's anyone else who joins as well. Um But welcome to the session. I hope you're having a good evening. Um We'll wait a couple, maybe one or two more minutes to see if anyone else joins and if not, we'll get started. Ok, we'll make a start. Um Welcome to the session on gastroenterology. Um My name is Sophia. I'm a, an fy one doctor working in North Manchester at the minute. Um My current placement is radiology. So this will incorporate quite a few scans and radiology that I think would be useful, not only for exams, but also for fy, um and my previous block was in surgery. Um And so I know a little bit of the Gastro and the surgical side of it. Um So let's get started. Um So the main learning outcomes today are just to know what the main uh presenting complaints of in Gastro are and how we can use our diagnostic skills to figure out what the diagnosis is um and we'll talk about interventions and management. We use the MLA as the basis for what topics to select. Um The ma does tend to highlight uh a couple topics. So we'll go over those in this session. But um just to make you aware, there are quite a few in here that we would recommend you read such as necrotizing enterocolitis that we won't cover today. Um but may very well come up in the exam. So, oh, so we'll do a question if you've been to any sessions before we do a question. We wait about a minute and then we'll go through the answers and explanations. So the first question, your minute starts. Now, six year old woman presents to the Ed with worsening, colicky abdominal pain, fatigue past two years, she's not jaundiced blood show elevated AP GGT and bilirubin. And on examination, there is marked garden since arriving in the Ed. She's vomiting and an Abdo X ray shows gas in the biliary tree. What's the most likely diagnosis and Paul since you're here? Um If you're ready, you can just say you're ready in the chat and we can move on. Ok. So that's about a minute. So, so this question is focusing on this woman who's had this abdo pain and you have all of these diagnoses that could be the potential diagnosis. The correct answer here is gallstone ileus and I'll explain why. So from the history, it sounds like she has a picture of cholecystitis and it seems like it's recurrent cholecystitis. So immediately off the bat, we're thinking it could be A B or C, it could be a cholangiocarcinoma. Recurrent cholecystitis is a risk factor for cholangiocarcinomas developing. It could be an acute episode of cholecystitis itself or it could be a gallstone ileus, especially with the gas in the tree and I'll come on to that in a minute. So, oh, so then we have a look at the vomiting and the pneumobilia. So gas in the biliary tree or the fancy name pneumobilia is pretty much patho pneumonic for gallstone ileus. And what that means is that a gallstone from the gallbladder has found its way into the uh gastrointestinal tract and it's called a blockage somewhere in the small, um, in the small intestine. And what that's done is because there's a small bowel obstruction. The, the patient will be feeling like they're vomiting. Um, they'll be feeling really unwell and that counts as an acute abdomen. So, why is it not cholangiocarcinoma in this case? So, she has had this for the past two years and she's also feeling fatigued, um, which could point towards cholangiocarcinoma as you know, fever, weight loss, um, and fatigue can all con can all point towards uh tumor, um, and to be fair as well. Um, cholangiocarcinomas can also lead lead to pneumobilia if the tumor erodes um from the gallbladder into the duodenum. So, but the key thing here is that she does not appear jaundiced, cholangiocarcinoma is normally a long term process that does present with um jaundice and a, a long term buildup of bilirubin. Um And you would expect a sort of more um chronic it, she might as well she could have a chronic background of this. But the acute problem that we're dealing with here is the gallstone ileus, especially with the vomiting and the patho pathic finding of the pneumobilia. So that's why this question I is highlighting what's the most likely diagnosis. Acute cholangitis tends to present with the Charcot triad. I always look for um abdominal pain, jaundice and fever. And if the question doesn't mention one, all of those, then I don't think about cholangitis and then biliary colic. So biliary colic is when the pain just comes and goes, but it wouldn't present so acutely like this so well done if you got that right. Um That's just a quick explanation. And as I said, gallstone ileus gallstones in the, in the bowel and how we'd investigate it. So, and, and like if you write notes and things, that's how I revised for med school, um I just wrote like Bloods and after X ray and then maybe act tap. Um but in practice, you'd actually do a whole host of bloods and that's really useful to know when you're doing osk exams. Um say, for example, you think a patient has this in an OSK, you would say um I would want to perform further tests such as bloods, fbcs using FT CRP. Um If it's an acute abdomen, you could always add in an amylase. I would want to order some blood cultures in case they are septic and then bedside other bedside tests alongside bloods. So you could do an A BGA VBG, an E CG. Um if the patient, patient is a woman and they have acute abdomal abdominal pain, almost always you do a pregnancy test. Um And another bedside test would be BMS. And then, so bloods, bedside tests and then imaging, I think about chest x rays in case there's perspiration, um ultrasound abdo if I'm suspecting a cholecystitis, um chest um No, I put chest X ray twice CT ABDO and then E RCP or M RCP and then for management of gallstone ileus. Um I don't know if you've heard of drip and drain before drip and drain is just a really quick way of remembering what to do if someone has a small bowel obstruction. So you want to drip them. So put in um a drip IV fluids and drain them. So put an NG tube and try to relieve all the fluid that's building up behind the obstruction because these patients, they might be vomiting quite a lot and they'll be um using quite a lot of electrolytes. I